Microbiota in vaginal health and pathogenesis of recurrent vulvovaginal infections: a critical review

Vaginal colonization and vertical transmission of Candida species: prevalence and associated factors among pregnant women and their neonates at public health facilities of Northeast Ethiopia

BACKGROUND

Vaginal colonization by Candida can lead to vulvovaginal candidiasis, which is the second most prevalent vaginal condition globally. It is frequently associated with sepsis and adverse neonatal outcomes in pregnant women. This issue is worsening in Sub-Saharan Africa, including Ethiopia. However, evidence of the existing problem is very scarce yet crucial. Thus, this study aimed to determine the vaginal colonization and vertical transmission of Candida species and their associated factors among pregnant women and their neonates in public health facilities of northeast Ethiopia.

METHODS

A facility-based cross-sectional study was conducted at selected public health facilities in Dessie town from April 1 to June 30, 2023, among 348 pregnant women and their newborns, using convenience sampling techniques. Socio-demographic, and clinical-related data were collected using a pre-tested, semi-structured questionnaire. Vaginal swab samples from pregnant women and pooled swabs from the external ear, nasal area, and umbilical areas of the newborns were collected and transported using Amies transport media. The samples were inoculated into Sabouraud Dextrose Agar for isolation, followed by inoculation onto a standard CHROM agar Candida plate for species identification, and a germ-tube test confirmed pseudophyphae of C.albicans. Data was entered into Epi Data version 4.6.0 software and exported and analyzed by SPSS version 25.0. A stepwise logistic regression model was used to identify the associated factors. Variables with p < 0.05 and their 95% confidence interval were considered statistically significant.

RESULT

A total of 348 pregnant women attending vaginal delivery were included in the study. The maternal and neonatal colonization rates of Candida species were 14.1% (49/348) and 6.3% (22/348), respectively. The overall proportion of vertical transmission of Candida species was 44.9% (22/49, 95% CI: 41.2, 49.7). Among Candida isolates, 63.3% (31/49) were C. albicans and 36.7% (18/49) were C. krusei. Gestational diabetes mellitus (AOR: 4.2, 95% CI: 1.23-38.6, P = 0.047) and HIV (AOR: 1.58, 95% CI: 1.11-6.12, P = 0.049) were independently associated with maternal colonization of Candida species. Moreover, rural residence (AOR = 3.6, 95% CI: 1.37-9.5, P = 0.010) and maternal age above 28 years (AOR = 2.39, 95% CI: 1.97-5.89, P = 0.048) were independently associated with vertical transmission of Candida species.

CONCLUSION

The findings of this study highlight the need for effective screening and treatment of Candida colonization during antenatal care.

Lactococcus lactis and Bifidobacterium bifidum alleviate postmenopausal symptoms by suppressing NF-κB signaling and microbiota dysbiosis

To understand the action mechanism of probiotics against postmenopausal symptoms, we examined the effects of Lactococcus lactis P32 (PL) and Bifidobacterium bifidum P45 (PB), which suppressed interleukin (IL)-6 and receptor activator of nuclear factor-κB (RANK) ligand (RNAKL) expression in Gardnerella vaginalis (Gv)-stimulated macrophages, on vaginitis, osteoporosis, and depression/cognitive impairment (DC) in mice with vaginally infected Gv, ovariectomy (Ov), or Ov/Gv (oG). Oral administration of PL or PB decreased Gv-induced DC-like behavior and tumor necrosis factor (TNF)-α, IL-6, RANK, and/or RANKL expression in the vagina, bone, hypothalamus, hippocampus, and colon, while Gv-suppressed bone osteoprotegerin and brain serotonin and brain-derived neurotrophic factor (BDNF) levels increased. They partially shifted vaginal and gut dysbiosis in Gv-infected mice to the gut microbiota composition in normal control mice. In mice with oG, oral administration of PL or PB decreased oG-induced DC-like behavior and TNF-α, IL-6, RANK, and/or RANKL expression in the vagina, bone, brain, and colon, while oG-suppressed bone osteoprotegerin and brain serotonin and BDNF levels increased. They also alleviated oG-induced vaginal and gut dysbiosis: they decreased Proteobacteria population. PL and PB (4:1) mix (PM) suppressed DC-like behavior in mice with Gv, Ov, or oG. PM also suppressed TNF-α, IL-6, RANK, and/or RANKL expression in the vagina, bone, colon, and brain. PM alleviated Gv-induced vaginal and gut dysbiosis: it decreased Proteobacteria population. These findings suggest that PL and PB, singly or together, can alleviate postmenopausal symptoms including vaginitis, colitis, osteoporosis, and DC by suppressing RANK/RANKL-mediated NF-κB activation and alleviating vaginal/gut microbiota dysbiosis.

Are We Able to Optimize Outcomes and Predict Complications in Pelvic Floor Surgery With a Better Understanding of Hormonal, Microbial and Other Factors? A Report From the ICI-RS 2024

INTRODUCTION

Pelvic organ prolapse (POP) is a common condition, affecting women worldwide and is known to have a significant impact on Health Related Quality of Life (HRQoL). Although there are various treatment options available, including pelvic floor muscle training and support pessaries, many women opt for or require surgery, with a lifetime risk of needing surgery of 12%-19%. As with any operation, this does not come without its complications and the reoperation rate following POP surgery is up to 36%. This International Consultation on Incontinence-Research Society (ICI-RS) report aims to look at the different factors which may play a role in objective and subjective outcomes following pelvic floor surgery and to summarize the evidence and uncertainties regarding prediction of POP surgical outcomes, how to optimize them and the tools available to predict them. Research question proposals to further this field have been highlighted.

METHODS

At ICI-RS 2024, the evidence for predicting the outcomes from POP surgery and methods to optimize outcomes were discussed and presented in this paper.

RESULTS

There are many reasons why POP surgery may fail, such as variations in lifestyle and occupation, persistent constipation, failure in the perineal body, connective tissue types or the shape of the pelvis. There may also be inherent conditions of the vagina, such as hormonal or microbial features. The literature lacks evidence about the potential use of advanced statistical modeling or supervised machine learning in the development of management plans for patients with POP. Furthermore, future research is needed to determine the role of UDS in the preoperative evaluation of POP patients.

CONCLUSIONS

High-quality powered studies are required to assess optimization for long-term outcomes of pelvic surgery and then, once these are well established, and possible interventions are elucidated, prediction modeling can have a real impact clinically.

Analysis of vaginal microbiota before and after treatment of high-grade squamous intraepithelial lesions of the uterine cervix

Objective

HPV infection is considered the most common sexually transmitted virus today. The persistence of HPV is the main cause for the development of precursor lesions and cervical cancer. There are environmental and non-environmental factors that contribute to the persistence of the virus. Studies indicate a possible relationship between the vaginal microbiota (environmental factor) and the risk of high-grade cervical squamous intraepithelial lesions and cervical cancer. This study evaluates the association between the type of vaginal microbiota and the occurrence of high-grade squamous intraepithelial lesions of the cervix.

Methods

Observational, longitudinal, prospective, and analytical studies carried out between 2019 and 2021, which evaluated the vaginal microbiota of patients diagnosed with high-grade cervical squamous intraepithelial lesion before and after treatment in two collections with an interval of 6 months, using scrapings and vaginal swabs.

Results

In Group I (with lesions) 28 women participated and 29 in Group II (without lesions). According to Nugent, in the initial collection of Group I, 16 women (57%) had lactobacillary microbiota, eight (28%) intermediate, and four (14%) coccus. In Group II, twenty-one (75%) were lactobacillary, one (3%) was intermediate, and seven (24%) werecoccus. With p=0.03.

Conclusion

According to Nugent's criteria, there was an association between the type of vaginal microbiota and the occurrence of high-grade cervical squamous intraepithelial lesions of the cervix. The same was not observed in the Donders classification. Studies with a larger sample are needed to confirm our results.

Vaginal prevention of Candida albicans: synergistic effect of lactobacilli and mannan oligosaccharides (MOS)

Vulvovaginal candidiasis (VVC) affects approximately 30-50% of women at least once during their lifetime, causing uncomfortable symptoms and limitations in their daily quality of life. Antifungal therapy is not very effective, does not prevent recurrencies and usually causes side effects. Therefore, alternative therapies are urgently needed. The goal of this work was to investigate the potential benefits of using mannan oligosaccharides (MOS) extracts together with a Lactobacillus sp. pool, composed by the most significant species present in the vaginal environment, to prevent infections by Candida albicans. Microbial growth of isolated strains of the main vaginal lactobacilli and Candida strains was assessed in the presence of MOS, to screen their impact upon growth. A pool of the lactobacilli was then tested against C. albicans in competition and prophylaxis studies; bacterial and yeast cell numbers were quantified in specific time points, and the above-mentioned studies were assessed in simulated vaginal fluid (SVF). Finally, adhesion to vaginal epithelial cells (HeLa) was also evaluated, once again resorting to simultaneous exposure (competition) or prophylaxis assays, aiming to measure the effect of MOS presence in pathogen adherence. Results demonstrated that MOS extracts have potential to prevent vaginal candidiasis in synergy with vaginal lactobacilli, with improved results than those obtained when using lactobacilli alone. KEY POINTS: Potential benefits of MOS extracts with vaginal lactobacilli to prevent C. albicans infections. MOS impacts on growth of vaginal lactobacilli pool and C. albicans in SVF. MOS extracts in synergy with L. crispatus inhibit C. albicans adhesion in HeLa cells.

Understanding vaginal biofilms: The first step in harnessing antimicrobial nanomedicine

In spite of multipurpose technologies offering broad-spectrum prevention for sexually transmitted infections (STIs) and contraception, the STIs incidences rise worldwide. The situation is even more alarming considering continuous rise in antimicrobial resistance (AMR) that limits therapy options. In this review we address the specific challenges of efficiently treating vaginal infections locally, at the infection site, by understanding the underlying barriers to efficient treatment such as vaginal biofilms. Knowledge on vaginal biofilms remains, up to now, rather scarce and requires more attention. We therefore propose a 'back to basics' insight that seeks to probe the complexity and role of the vaginal microbiota, its relationship with vaginal biofilms and implications to future therapeutic modalities utilizing advanced nano delivery systems. Our key objective is to highlight the interplay between biofilm, (nano)formulation and therapy outcome rather than provide an overview of all nanoformulations that were challenged against biofilms. We focused on the anatomy of the female reproductive organ and its physiological changes from birth, the unique vaginal microenvironment in premenopausal and postmenopausal women, vaginal biofilm infections and current nanomedicine-based approaches to treat infections in the vaginal site. Finally, we offer our perspectives on the current challenges associated with vaginal delivery and key considerations that can aid in the design and development of safer and potent products against persisting vaginal infections.

Highlight signatures of vaginal microbiota and metabolome contributed to the occurrence and recurrence of vulvovaginal candidiasis

Vulvovaginal candidiasis (VVC) is a common vaginal infectious disease caused by Candida. The high recurrence rate of VVC is a great clinical challenge, with recurrent VVC (RVVC) defined as four or more episodes within a year. In this study, we recruited 31 RVVC patients, 28 VVC patients, and 29 healthy women. Vaginal samples were collected for metagenomic and metabolic analysis. RVVC and VVC groups presented similar clinical symptoms, with only a significantly increased incidence of swelling in the VVC group. Vaginal microbiota in VVC/RVVC exhibited a decreased abundance of Lactobacillus and increased bacterial vaginosis-associated bacteria, such as Gardnerella, Prevotella, and Atopobium. Notably, Lactobacillus iners was higher in RVVC, suggesting not all Lactobacillus species are protective. Healthy women showed lower overall microbiota diversity, emphasizing single-species dominance for stability. Glycogen metabolism pathways were enriched in RVVC/VVC, and were correlated with Atopobium vaginae, Prevotella bivia, and Lactobacillus jensenii. Peptidoglycan synthesis pathways, associated with P. bivia, were enriched, with the substrate L-glutamate elevated in RVVC, possibly promoted by L. iners. These findings shed light on potential therapeutic targets for recurrent VVC, contributing to the understanding of the intricate interplay between the metabolism of vaginal microbiome and disease.

IMPORTANCE

This study enhances our knowledge of the vaginal microbiota dynamics and the role of associated metabolites in individuals with vulvovaginal candidiasis (VVC) and recurrent vulvovaginal candidiasis through shotgun sequencing and multi-omics analysis. The relationship between metabolites and vaginal microbiota and disease state was revealed. The accumulation of L-glutamate generated in glycogen metabolism, which is governed by Lactobacillus iners or bacterial vaginosis-associated bacteria, may contribute to the incidence and recurrence of VVC. Such insights have the potential to impact the treatment and prevention strategies for these common yet distressing conditions, potentially leading to targeted therapies and improved patient outcomes.

Progesterone promotes CXCl2-dependent vaginal neutrophil killing by activating cervical resident macrophage-neutrophil crosstalk

Vaginal infections in women of reproductive age represent a clinical dilemma with significant socioeconomic implications. The current understanding of mucosal immunity failure during early pathogenic invasions that allows the pathogen to grow and thrive is far from complete. Neutrophils infiltrate most tissues following circadian patterns as part of normal repair, regulation of microbiota, or immune surveillance and become more numerous after infection. Neutrophils are responsible for maintaining vaginal immunity. Specific to the vagina, neutrophils continuously infiltrate at high levels, although during ovulation, they retreat to avoid sperm damage and permit reproduction. Here we show that, after ovulation, progesterone promotes resident vaginal macrophage-neutrophil crosstalk by upregulating Yolk sac early fetal organs (FOLR2+) macrophage CXCl2 expression, in a TNFA-patrolling monocyte-derived macrophage-mediated (CX3CR1hiMHCIIhi-mediated) manner, to activate the neutrophils' capacity to eliminate sex-transmitted and opportunistic microorganisms. Indeed, progesterone plays an essential role in conciliating the balance between the commensal microbiota, sperm, and the threat of pathogens because progesterone not only promotes a flurry of neutrophils but also increases neutrophilic fury to restore immunity after ovulation to thwart pathogenic invasion after intercourse. Therefore, modest progesterone dysregulations could lead to a suboptimal neutrophilic response, resulting in insufficient mucosal defense and recurrent unresolved infections.

The association between lifestyle factors and the composition of the vaginal microbiota: a review

PURPOSE

The vaginal microbiota offers valuable insights into women's sexual health and the risk of developing sexually transmitted infections (STIs) and bacterial vaginosis. Despite the public health implications of changes in the vaginal environment, existing data on this topic remain sparse.

METHODS

Following the PRISMA statement guidelines, we consulted five bibliographic databases, focusing on five main daily habits and behaviors. We included only studies published up to October 2023, investigating the influence of personal hygiene, sexual behaviors, hormonal contraception, smoking, alcohol consumption, and psychosocial stress on the vaginal microbiota using next-generation sequencing.

RESULTS

Based on our inclusion criteria, we incorporated 37 studies into this review. Hormonal contraception and personal hygiene were found to promote eubiosis of the vaginal microbiota. In contrast, sexual behaviors, smoking, alcohol consumption, and psychosocial stress were associated with an increased susceptibility to bacterial vaginosis, STIs, and severe pelvic inflammatory diseases due to a modified vaginal microbiota. Black ethnicity emerged as a confounding factor, with this population showing unstable vaginal microbiota. Oral contraception and a stable male sexual partner were found to favor Lactobacillus colonization, acting as a protective factor. Conversely, non-hormonal contraception and unprotected or non-penile/vaginal sexual activity increased the incidence of vaginal inflammation and bacterial vaginosis by disturbing the vaginal microbiota and reducing Lactobacillus abundance.

CONCLUSION

Daily habits and lifestyle can influence the composition of the vaginal microbiota, thereby affecting vaginal health. Disturbances in the vaginal microbiota could be associated factors for STIs and vaginosis. Therefore, prioritizing more appropriate management of the vaginal microbiota is crucial.

Mechanisms of action of Lactobacillus spp. in the treatment of oral candidiasis

Candida albicans is often associated with oral candidiasis, and drug-resistance profiles have contributed to an increase in morbidity and mortality. It is known that Lactobacillus spp. acts by competing for adhesion to the epithelium, absorption of nutrients and modulation of the human microbiota. Therefore, they are important to assist in the host's microbiological balance and reduce the growth of Candida spp. Until now, there have been no reports in the literature of reviews correlating to the use of Lactobacillus spp. in the treatment of oral candidiasis. Thus, this review aims to highlight the mechanisms of action of Lactobacillus spp. and methods that can be used in the treatment of oral candidiasis. This is a study carried out through the databases PubMed Central and Scientific Electronic Library Online, using the following keywords: Oral Candidiasis and Lactobacillus. Original articles about oral candidiasis were included, with both in vitro and in vivo analyses, and published from 2012 to 2022. Lactobacillus rhamnosus was the most common microorganism used in the experiments against Candida, acting mainly in the reduction of biofilm, filamentation, and competing for adhesion sites of Candida spp. Among in vivo studies, most researchers used immunosuppressed mouse modelsof Candida infection. The studies showed that Lactobacillus has a great potential as a probiotic, acting mainly in the prevention and treatment of mucosal diseases. Thus, the use of Lactobacillus may be a good strategy for the treatment of oral candidiasis.

Chitosan and liposomal delivery systems for epicatechin or propyl gallate targeting localized treatment of vulvovaginal candidiasis

Natural polyphenols are promising alternatives to antifungals for novel treatments of vulvovaginal candidiasis (VVC) in an era of antimicrobial resistance. However, polyphenols are poorly soluble and prone to degradation. To overcome their limitations, we propose incorporation in liposomes. The study aimed to develop chitosan and liposome comprising delivery systems for epicatechin (EC) or propyl gallate (PG) as treatment of VVC. EC was selected for its antioxidative properties and PG as an ester of antifungal gallic acid. To improve formulation retention at vaginal site, mucoadhesive chitosan was introduced into formulation as liposomal surface coating or hydrogel due to intrinsic antifungal properties. These polyphenol-loaded liposomes exhibited an average size of 125 nm with a 64 % entrapment efficiency (for both polyphenols). A sustained in vitro polyphenol release was seen from liposomes, particularly in chitosan hydrogel (p < 0.01 or lower). Viscosity was evaluated since increased viscosity upon mucin contact indicated adhesive bond formation between chitosan and mucin confirming mucoadhesiveness of formulations. Antifungal activity was evaluated by the broth microdilution method on Candida albicans CRM-10231. Unlike PG, incorporation of EC in liposomes enabled antifungal activity. Fungicidal activity of chitosan was confirmed both when used as liposomal coating material and as hydrogel vehicle.

The microbial revolution: Unveiling the benefits of vaginal probiotics and prebiotics

Vaginal health is essential to a woman's overall well-being, as abnormalities in vaginal health can lead to a variety of gynaecological disorders, such as urinary tract infections, yeast infections, and bacterial vaginosis. The vaginal microbiome is essential for the prevention of these infections. Disruptions in this microbial ecosystem can significantly impact vaginal health. The concept of utilizing probiotics and prebiotics to stimulate the growth of protective vaginal microbiota has gathered substantial interest in recent years. Probiotics are live micro-organisms that strengthen and restore vaginal microbial balance by lowering pH levels, production of bacteriocins, biofilm disruption, modulation of immune response, and production of hydrogen peroxide (H2O2), consequently combating the development of pathogens. Prebiotics are oligosaccharides that encourage the development of probiotics such as lactobacilli species. Probiotics and prebiotics also have some broader implications for vaginal health, including their role in minimizing the incidence of premature birth, optimizing fertility, managing menopausal symptoms, and preventing vaginal infections. Synbiotics are a combination of probiotics and prebiotics that deliver additional benefits by encouraging the development and activity of beneficial microbes. Furthermore, postbiotics are bioactive compounds derived from probiotic bacteria during fermentation that have immunomodulatory actions and provide an additional layer of protection against vaginal infections. The present study highlights the most prevalent vaginal infections and limitations of existing therapies that influence the vaginal microbiota. The profound consequences of probiotics and prebiotics in women's health, including their role in minimizing the prevalence of vaginal infections and promoting overall vaginal health, as well as advanced therapeutic strategies such as synbiotics and postbiotics, are also discussed. The literature offers significant insights into the mechanism, efficacy, and safety of probiotics and prebiotics to healthcare providers and researchers.

Vaginal and endometrial microbiome dysbiosis associated with adverse embryo transfer outcomes

BACKGROUND

Assisted reproductive technology (ART) is the most effective method to treat infertility and the pathogenesis of implantation failure after in vitro fertilization-embryo transfer (IVF-ET) is a challenging filed in infertility. Microbes in the female reproductive tract are considered to be associated with gynecological and obstetric diseases. However, its effects on embryo implantation failure are unsured.

PURPOSE

This study aimed to investigate reproductive tract dysbiosis, identify different bacteria in reproductive tract as potential biomarkers of embryo implantation failure and demonstrate the pathogenesis through metabolites analysis.

METHODS

We compared the data from 16S rRNA gene and metagenome in reproductive tracts through QIIME2 and HUMAnN2 by the times of embryo implantation failure on 239 infertile patients and 17 healthy women.

RESULTS

Our study revealed a strong positive correlation between Lactobacillus abundance and embryo implantation success (IS) after IVF-ET. The microbial community composition and structure in reproductive tract showed substantially difference between the embryo implantation failure (IF) and healthy control. Moreover, we established a diagnostic model through receiver operating characteristic (ROC) with 0.913 area under curve (AUC) in IS and multiple implantation failures (MIF), verified its effectiveness with an AUC = 0.784 demonstrating microbial community alterations could efficiently discriminate MIF patients. Metagenome functional analyses of vaginal samples from another independent infertile patients after IVF-ET revealed the L-lysine synthesis pathway enriched in IF patients, along with ascended vaginal pH and decreased Lactobacillus abundance.

CONCLUSIONS

This study clarifies several independent relationships of bacteria in vagina and endometrial fluid on embryo implantation failure and undoubtedly broadens the understanding about female reproductive health.

The influence of the vaginal ecosystem on vaginitis, bacterial vaginosis, and sexually transmitted diseases: an epidemiological study and literature review

PURPOSE

This study aimed to demonstrate the correlation between altered balance of the vaginal ecosystem and increased risk of vaginitis, bacterial vaginosis, and sexually transmitted diseases and the association between specific alterations found in fresh bacterioscopic examinations (FBE) and the risk of certain infections.

METHODS

A retrospective, monocentric study was conducted from January 2013 to December 2023. Patients who underwent FBE and vaginal swabs following reported symptoms or suspected syndromic pictures of vulvovaginal infections were included.

RESULTS

Two thousand one hundred ten patients were included and divided into a control group (n = 811, 38.4%) and a pathological group (n = 1299 patients, 61.6%), based on the presence of alterations at the FBE. In the pathological group, 1185 women (91% of positive FBE) had vaginal infections detected through vaginal swabs. The presence of lactobacilli and typical inflammatory cells was detected in 111 (8%) women with pathological FBE and correlated with higher rates of positive swabs for common germs (n = 104, 94%), often leading to co-infections (n = 30, 29%). Conversely, Döderlein's cytolysis (n = 56, 4.3% of positive FBE) indicated a predominance of positive human papillomavirus (HPV) swabs (n = 33, 59%). The presence of fungal elements (n = 208, 16% of positive FBE) suggested a higher prevalence of co-infections (n = 62, 30%). Similarly, mixed bacterial flora (n = 470, 36% of positive FBE) and Trichomonas vaginalis (n = 11, 0.8% of positive FBE) correlated with positive swabs for other pathogens, except for Mycoplasma (n = 0). Bacterial vaginosis (n = 443, 34% of positive FBE) was linked to co-infections (n = 142, 32%) and HPV (n = 123, 28%).

CONCLUSION

The importance of conducting FBE in patients with vulvovaginal symptoms is emphasized. This approach aids in determining the need for further diagnostic tests like vaginal swabs, guided by microscopic findings. A strong correlation emerges between the presence of specific alterations in the FBE and an increased prevalence of certain infections.

Towards a Wearable Feminine Hygiene Platform for Detection of Invasive Fungal Pathogens via Gold Nanoparticle Aggregation

Candida albicans is an opportunistic fungus that becomes pathogenic and problematic under certain biological conditions. C. albicans may cause painful and uncomfortable symptoms, as well as deaths in immunocompromised patients. Therefore, early detection of C. albicans is essential. However, conventional detection methods are costly, slow, and inaccessible to women in remote or developing areas. To address these concerns, we have developed a wearable and discrete naked-eye detectable colorimetric platform for C. albicans detection. With some modification, this platform is designed to be directly adhered to existing feminine hygiene pads. Our platform is rapid, inexpensive, user-friendly, and disposable and only requires three steps: (i) the addition of vaginal fluid onto sample pads; (ii) the addition of gold nanoparticle gel and running buffer, and (iii) naked eye detection. Our platform is underpinned by selective thiolated aptamer-based recognition of 1,3-β-D glucan molecules-a hallmark of C. albicans cell walls. In the absence of C. albicans, wearable sample pads turn bright pink. In the presence of C. albicans, the wearable pads turn dark blue due to significant nanoparticle target-induced aggregation. We demonstrate naked-eye colorimetric detection of 4.4 × 106C. albicans cells per ml and nanoparticle stability over a pH range of 3.0-8.0. We believe that this proof-of-concept platform has the potential to have a significant impact on women's health globally.

The evolving facets of vaginal microbiota transplantation: reinvigorating the unexplored frontier amid complex challenges

In an age of cutting-edge sequencing methods and worldwide endeavors such as The Human Microbiome Project and MetaHIT, the human microbiome stands as a complex and diverse community of microorganisms. A central theme in current scientific inquiry revolves around reinstating a balanced microbial composition, referred to as "eubiosis," as a targeted approach for treating vast array of diseases. Vaginal Microbiota Transplantation (VMT), inspired by the success of fecal microbiota transplantation, emerges as an innovative therapy addressing vaginal dysbacteriosis by transferring the complete microbiota from a healthy donor. Antibiotics, while effective, pose challenges with adverse effects, high recurrence rates, and potential harm to beneficial Lactobacillus strains. Continued antibiotic usage also sparks worries regarding the development of resistant strains. Probiotics, though showing promise, exhibit inconsistency in treating multifactorial diseases, and concerns linger about their suitability for diverse genetic backgrounds. Given the recurrent challenges associated with antibiotic and probiotic treatments, VMT emerges as an imperative alternative, offering a unique and promising avenue for efficiently and reliably managing vaginal dysbiosis among a majority of women. This review critically evaluates findings from both animal and human studies, offering nuanced insights into the efficacy and challenges of VMT. An extensive analysis of clinical trials, provides a current overview of ongoing and completed trials, shedding light on the evolving clinical landscape and therapeutic potential of VMT. Delving into the origins, mechanisms, and optimized protocols of VMT, the review underscores the imperative for sustained research efforts to advance this groundbreaking gynecological therapy.

Diet influences community dynamics following vaginal group B streptococcus colonization

The vaginal microbiota plays a pivotal role in reproductive, sexual, and perinatal health and disease. Unlike the well-established connections between diet, metabolism, and the intestinal microbiota, parallel mechanisms influencing the vaginal microbiota and pathogen colonization remain overlooked. In this study, we combine a mouse model of Streptococcus agalactiae strain COH1 [group B Streptococcus (GBS)] vaginal colonization with a mouse model of pubertal-onset obesity to assess diet as a determinant of vaginal microbiota composition and its role in colonization resistance. We leveraged culture-dependent assessment of GBS clearance and culture-independent, sequencing-based reconstruction of the vaginal microbiota in relation to diet, obesity, glucose tolerance, and microbial dynamics across time scales. Our findings demonstrate that excessive body weight gain and glucose intolerance are not associated with vaginal GBS density or timing of clearance. Diets high in fat and low in soluble fiber are associated with vaginal GBS persistence, and changes in vaginal microbiota structure and composition due to diet contribute to GBS clearance patterns in nonpregnant mice. These findings underscore a critical need for studies on diet as a key determinant of vaginal microbiota composition and its relevance to reproductive and perinatal outcomes.IMPORTANCEThis work sheds light on diet as a key determinant influencing the composition of vaginal microbiota and its involvement in group B Streptococcus (GBS) colonization in a mouse model. This study shows that mice fed diets with different nutritional composition display differences in GBS density and timing of clearance in the female reproductive tract. These findings are particularly significant given clear links between GBS and adverse reproductive and neonatal outcomes, advancing our understanding by identifying critical connections between dietary components, factors originating from the intestinal tract, vaginal microbiota, and reproductive outcomes.

Microorganism-derived extracellular vesicles: emerging contributors to female reproductive health

Extracellular vesicles (EVs) are cell-derived nanoparticles that carry small molecules, nucleic acids, and proteins long distances in the body facilitating cell-cell communication. Microorganism-derived EVs mediate communication between parent cells and host cells, with recent evidence supporting their role in biofilm formation, horizontal gene transfer, and suppression of the host immune system. As lipid-bound bacterial byproducts, EVs demonstrate improved cellular uptake and distribution in vivo compared to cell-free nucleic acids, proteins, or small molecules, allowing these biological nanoparticles to recapitulate the effects of parent cells and contribute to a range of human health outcomes. Here, we focus on how EVs derived from vaginal microorganisms contribute to gynecologic and obstetric outcomes. As the composition of the vaginal microbiome significantly impacts women's health, we discuss bacterial EVs from both healthy and dysbiotic vaginal microbiota. We also examine recent work done to evaluate the role of EVs from common vaginal bacterial, fungal, and parasitic pathogens in pathogenesis of female reproductive tract disease. We highlight evidence for the role of EVs in women's health, gaps in current knowledge, and opportunities for future work. Finally, we discuss how leveraging the innate interactions between microorganisms and mammalian cells may establish EVs as a novel therapeutic modality for gynecologic and obstetric indications.

From plants to particles: herbal solutions and nanotechnology combating resistant vulvovaginal candidiasis

Despite having current advanced therapy, vulvovaginal candidiasis (VVC) remains a common yet debated healthcare-associated topic worldwide due to multi-drug resistance Candida species. In our review, we outlined and highlighted upcoming values with scope of existing and emerging information regarding the possibility of using various natural molecules combined with modern technology that shows promising anti-candida activity in VVC. Furthermore, in this review, we compiled herbal drug molecules and their nanocarriers approach for enhancing the efficacy and stability of herbal molecules. We have also summarized the patent literature available on herbal drug molecules and their nanoformulation techniques that could alternatively become a new innovative era to combat resistance VVC.

Recurrent Peritonsillar Abscess Caused by Vaginal Flora: A Common Problem From a Unique Source

Peritonsillar abscesses (PTAs) are typically caused by group A Streptococcus or mixed oral flora. Gardnerella vaginalis is a part of the normal vaginal microbiome, and overgrowth can cause bacterial vaginosis. We present a case of recurrent PTA with G. vaginalis superinfection, which occurred after the patient performed oral sex on a female after incision and drainage of her initial PTA. The patient continued to have recurrent PTAs until G. vaginalis was identified, and antibiotic coverage was broadened to cover both group A Streptococcus and G. vaginalis. This case highlights the importance of culturing PTA aspirate for directed antibiosis in persistent or recurrent infections. The rare superinfection also raises the question of advising abstinence from oral-genital contact after oral procedures to minimize risk of superinfection.

Cervicovaginal microbiota: a promising direction for prevention and treatment in cervical cancer

Cervical cancer is a common malignancy in women, with high incidence rate and mortality. Persistent infection of high-risk human papillomavirus (HPV) is the most important risk factor for cervical cancer and precancerous lesions. Cervicovaginal microbiota (CVM) plays an essential role in the defense of HPV infections and prevention of subsequent lesions. Dominance of Lactobacillus is the key of CVM homeostasis, which can be regulated by host, exogenous and endogenous factors. Dysbiosis of CVM, including altered microbial, metabolic, and immune signatures, can contribute to persist HPV infection, leading to cervical cancer. However, there is no evidence of the causality between CVM and cervical cancer, and the underlying mechanism remains unexplored. Considering the close correlation between CVM dysbiosis and persistent HPV infection, this review will overview CVM, its role in cervical cancer development and related mechanisms, and the prospects for therapeutic applications.

Phytotherapy of Vulvovaginal Candidiasis: A Narrative Review

Vulvovaginal candidiasis (VVC) is a real gynecological problem among women of reproductive age from 15 to 49. A recent analysis showed that 75% of women will have an occurrence at least once per year, while 5% are observed to have recurrent vaginal mycosis-these patients may become unwell four or more times a year. This pathology is caused in 85-90% of cases by fungi of the Candida albicans species. It represents an intractable medical problem for female patients due to pain and pruritus. Due to the observation of an increasing number of strains resistant to standard preparations and an increase in the recurrence of this pathology when using local or oral preferential therapy, such as fluconazole, an analysis was launched to develop alternative methods of treating VVC using herbs such as dill, turmeric, and berberine. An in-depth analysis of databases that include scientific articles from recent years made it possible to draw satisfactory conclusions supporting the validity of herbal therapy for the pathology in question. Although phytotherapy has not yet been approved by the Food and Drug Administration, it appears to be a promising therapeutic solution for strains that are resistant to existing treatments. There is research currently undergoing aimed at comparing classical pharmacotherapy and herbal therapy in the treatment of vaginal candidiasis for the purpose of increasing medical competence and knowledge for the care of the health and long-term comfort of gynecological patients.

Interpretation of vaginal metagenomic characteristics in different types of vaginitis

Although vaginitis is closely related to vaginal microecology in females, the precise composition and functional potential of different types of vaginitis remain unclear. Here, metagenomic sequencing was applied to analyze the vaginal flora in patients with various forms of vaginitis, including cases with a clue cell proportion ranging from 1% to 20% (Clue1_20), bacterial vaginitis (BV), vulvovaginal candidiasis (VVC), and BV combined with VVC (VVC_BV). Our results identified Prevotella as an important biomarker between BV and Clue1_20. Moreover, a gradual decrease was observed in the relative abundance of shikimic acid metabolism associated with bacteria producing indole as well as a decline in the abundance of Gardnerella vaginalis in patients with BV, Clue1_20, and healthy women. Interestingly, the vaginal flora of patients in the VVC_BV group exhibited structural similarities to that of the VVC group, and its potentially functional characteristics resembled those of the BV and VVC groups. Finally, Lactobacillus crispatus was found in high abundance in healthy samples, greatly contributing to the stability of the vaginal environment. For the further study of L. crispatus, we isolated five strains of L. crispatus from healthy samples and evaluated their capacity to inhibit G. vaginalis biofilms and produce lactic acid in vitro to select the potential probiotic candidate for improving vaginitis in future clinical studies. Overall, we successfully identified bacterial biomarkers of different vaginitis and characterized the dynamic shifts in vaginal flora between patients with BV and healthy females. This research advances our understanding and holds great promise in enhancing clinical approaches for the treatment of vaginitis.

IMPORTANCE

Vaginitis is one of the most common gynecological diseases, mostly caused by infections of pathogens such as Candida albicans and Gardnerella vaginalis. In recent years, it has been found that the stability of the vaginal flora plays an important role in vaginitis. Furthermore, the abundant Lactobacillus-producing rich lactic acid in the vagina provides a healthy acidic environment such as Lactobacillus crispatus. The metabolites of Lactobacillus can inhibit the colonization of pathogens. Here, we collected the vaginal samples of patients with bacterial vaginitis (BV), vulvovaginal candidiasis (VVC), and BV combined with VVC to discover the differences and relationships among the different kinds of vaginitis by metagenomic sequencing. Furthermore, because of the importance of L. crispatus in promoting vaginal health, we isolated multiple strains from vaginal samples of healthy females and chose the most promising strain with potential probiotic benefits to provide clinical implications for treatment strategies.

Establishment and application of a rapid molecular diagnostic platform for the isothermal visual amplification of group B Streptococcus based on recombinase polymerase

With growing concerns about Group B streptococcal (GBS) infections and their adverse effects on perinatal pregnancies, including infection, premature delivery, neonatal septicemia, and meningitis, it is urgent to promote GBS screening at all pregnancy stages. The purpose of this study is to establish a device-independent, fast, sensitive, and visual GBS detection method. Taking advantage of the characteristics of the recombinase polymerase isothermal amplification (RPA), the activity of the nfo nuclease cleavage base analog (tetrahydrofuran, THF) site, and the advantages of visual reading of the lateral flow chromatography strip (LFS), a GBS detection method was developed. This method focused on the conservative region of the Christie-Atkins-Munch-Petersen factor encoded by the cfb gene, a virulence gene specific to GBS. Two forward primers, two biotin-labeled reverse primers, and one fluorescein isothiocyanate (FITC)-labeled and C3spacer-blocked probe were designed. The study involved optimizing the primer pair and probe combination, determining the optimal reaction temperature and time, evaluating specificity, analyzing detection limits, and testing the method on 87 vaginal swabs from perinatal pregnant women. The results showed that the visual detection method of GBS-RPA-LFS, using the cfb-F1/R2/P1 primer probe, could detect GBS within 15 min at the temperature ranging from 39°C to 42°C. Furthermore, the method specifically amplified only GBS, without cross-reacting with pathogens like Lactobacillus iners, Lactobacillus crispatus, Candida albicans, Listeria monocytogenes, Yersinia enterocolitica, Klebsiella Pneumoniae, Enterobacter cloacae, Citrobacter freundii, Vibrio alginolyticus, Vibrio parahaemolyticus, Salmonella typhimurium, Staphylococcus aureus, Pseudomonas aeruginosa, or Trichomonas vaginalis. It could detect a minimum of 100 copies per reaction. In clinical 98 samples of vaginal swabs from pregnant women, the agreement rate between the GBS-RPA-LFS method and TaqMan real-time fluorescence quantification method was 95.92%. In conclusion, this study successfully established a combined RPA and LFS GBS in situ detection platform, with short reaction time, high sensitivity, high specificity, portability, and device independence, providing a feasible strategy for clinical GBS screening.

Temporal changes in ewe vaginal microbiota throughout gestation

Introduction

Numerous factors are known to influence reproductive efficiency in ewes, but few studies have investigated the potential role of vaginal microbiota in sheep reproductive success. The objective of this study was to thoroughly characterize the ewe vaginal microbiota throughout the course of pregnancy.

Methods

Vaginal samples were collected from 31 pregnant Hampshire and Hampshire X Suffolk crossbred ewes on a weekly basis from pre-breeding to pregnancy testing and then biweekly until just after lambing. To characterize the vaginal microbial communities, DNA was extracted and 16S rRNA gene Illumina MiSeq amplicon sequencing was performed.

Results and Discussion

Alpha diversity metrics indicated an increase in species richness, evenness, and overall diversity throughout gestation. Distinct shifts in the bacterial communities were observed during gestation and were segregated into three periods: early gestation, a transitional period and mid/late gestation. During early gestation, Actinobacillus, Histophilus, and unclassified Leptotrichiaceae were found in greater relative abundance. During the transitional period, a population shift occurred characterized by increasing relative abundance of Streptococcus and Staphylococcus. During mid/late gestation, Staphylococcus, Streptococcus, and Ureaplasma had the greatest relative abundance. These shifts in the microbial population throughout the ewe's gestation are likely related to hormonal changes triggered by the growing conceptus, specifically increasing blood concentration of progesterone. The transitional period shift in vaginal microbial communities potentially aligns with the placental take-over of progesterone production from the corpus luteum at approximately day 50 after conception (gestational week 7). Understanding the observed variability of the vaginal microbiota throughout pregnancy will allow for future comparison of ewes that did not become pregnant or had abnormal pregnancies, which could lead to the discovery of potential bacterial biomarkers for pregnancy outcome; this understanding could also lead to development of probiotics to improve sheep reproductive success.

Bacteria-based drug delivery for treating non-oncological diseases

Bacteria inhabit all over the human body, especially the skin, gastrointestinal tract, respiratory tract, urogenital tract, as well as specific lesion sites, such as wound and tumor. By leveraging their distinctive attributes including rapid proliferation, inherent abilities to colonize various biointerfaces in vivo and produce diverse biomolecules, and the flexibility to be functionalized via genetic engineering or surface modification, bacteria have been widely developed as living therapeutic agents, showing promising potential to make a great impact on the exploration of advanced drug delivery systems. In this review, we present an overview of bacteria-based drug delivery and its applications in treating non-oncological diseases. We systematically summarize the physiological positions where living bacterial therapeutic agents can be delivered to, including the skin, gastrointestinal tract, respiratory tract, and female genital tract. We discuss the success of using bacteria-based drug delivery systems in the treatment of diseases that occur in specific locations, such as skin wound healing/infection, inflammatory bowel disease, respiratory diseases, and vaginitis. We also discuss the advantages as well as the limitations of these living therapeutics and bacteria-based drug delivery, highlighting the key points that need to be considered for further translation. This review article may provide unique insights for designing next-generation bacteria-based therapeutics and developing advanced drug delivery systems.

Instant Candida albicans Detection Using Ultra-Stable Aptamer Conjugated Gold Nanoparticles

Fungal pathogens such as Candida albicans have significant impacts on women's health and the economy worldwide. Current detection methods often require access to laboratory facilities that are costly, inconvenient, and slow to access. This often leads to self-diagnosis, self-treatment and eventual antifungal resistance. We have created a rapid (within five minutes), cost-effective, and user-friendly method for the early detection of Candida albicans. Our platform utilises aptamer-tagged-gold-core-shell nanoparticles for Candida albicans detection based on the presence of 1,3-β-d glucan molecules. Nanoparticle aggregation occurs in the presence of Candida albicans fungal cells, causing a redshift in the UV-visible absorbance, turning from pink/purple to blue. This colour change is perceptible by the naked eye and provides a "yes"/"no" result. Our platform was also capable of detecting Candida albicans from individual yeast colonies without prior sample processing, dilution or purification. Candida albicans yeast cells were detected with our platform at concentrations as low as 5 × 105 cells within a 50 μL sample volume. We believe that this technology has the potential to revolutionise women's health, enabling women to test for Candida albicans accurately and reliably from home. This approach would be advantageous within remote or developing areas.

Bacterial Vaginosis and Vulvovaginal Candidiasis Pathophysiologic Interrelationship

Among the infectious causes of vulvovaginal symptoms, bacterial vaginosis (BV) and vulvovaginal candidiasis (VVC) dominate. Apart from infrequent mixed infections, both are considered independent and caused by unrelated pathogenic mechanisms. Clinical experience, however, is strongly suggestive that in some populations these infections are linked with recurrent BV (RBV) serving as the dominant etiopathogenic trigger for development of recurrent VVC (RVVC) with profound clinical and therapeutic consequences. The biologic basis for this critical interrelationship is discussed and suggests that as a consequence of BV dysbiosis, and not necessarily because of antibiotics prescribed, immune defenses are compromised, neutralizing vaginal yeast tolerance. The consequent BV-induced vaginal proinflammatory environment predisposes to mixed infection or consecutive episodes of post-treatment VVC. Recurrent BV and repeated antimicrobial drug exposure also predispose to acquired fluconazole resistance in C. albicans isolates, contributing to refractory vulvovaginal candidiasis.

Gestational diabetes mellitus: genetic factors, epigenetic alterations, and microbial composition

Gestational diabetes mellitus (GDM) is a common metabolic disorder, usually diagnosed during the third trimester of pregnancy that usually disappears after delivery. In GDM, the excess of glucose, fatty acids, and amino acids results in foetuses large for gestational age. Hyperglycaemia and insulin resistance accelerate the metabolism, raising the oxygen demand, and creating chronic hypoxia and inflammation. Women who experienced GDM and their offspring are at risk of developing type-2 diabetes, obesity, and other metabolic or cardiovascular conditions later in life. Genetic factors may predispose the development of GDM; however, they do not account for all GDM cases; lifestyle and diet also play important roles in GDM development by modulating epigenetic signatures and the body's microbial composition; therefore, this is a condition with a complex, multifactorial aetiology. In this context, we revised published reports describing GDM-associated single-nucleotide polymorphisms (SNPs), DNA methylation and microRNA expression in different tissues (such as placenta, umbilical cord, adipose tissue, and peripheral blood), and microbial composition in the gut, oral cavity, and vagina from pregnant women with GDM, as well as the bacterial composition of the offspring. Altogether, these reports indicate that a number of SNPs are associated to GDM phenotypes and may predispose the development of the disease. However, extrinsic factors (lifestyle, nutrition) modulate, through epigenetic mechanisms, the risk of developing the disease, and some association exists between the microbial composition with GDM in an organ-specific manner. Genes, epigenetic signatures, and microbiota could be transferred to the offspring, increasing the possibility of developing chronic degenerative conditions through postnatal life.

The pathogenic and colonization potential of Candida africana

The Candida albicans population displays high genetic diversity illustrated by 18-well differentiated genetic clusters. Cluster 13, also known as Candida africana, is an outlying cluster and includes strains first described as atypical C. albicans isolates of vaginal origin, showing apparent tropism for the female genital tract. In our study, we combined in vitro, and in vivo models to explore the colonization and pathogenic potential of C. africana. We report that C. africana has similar fitness to C. albicans when it comes to colonization of the oral and vaginal mucosa, however it has decreased fitness in gastro-intestinal colonization and systemic infection. Interestingly, despite high population homogeneity, our in vitro data highlighted for the first time a variability in terms of growth rate, biofilm formation and filamentation properties between C. africana strains. Overall, our data lays the foundations for exploring specific features of C. africana that might contribute to its apparent niche restriction.

Evaluation of exoenzyme profiles of Candida albicans species isolated from females with vaginal candidiasis

Background and Purpose

The three most common causes of vaginitis are bacteria, yeast, and Protozoa. Candida albicans is one of the most common causes of vaginitis and commonly affects millions of females with different signs and symptoms. Secretion of exoenzymes from Candida species plays an important role in virulence and pathogenesis. Increasing our knowledge about the pathogenesis of candidiasis could help to design new anti-Candida drugs. This study aimed to evaluate the phospholipase, esterase, and hemolysin activities of the vaginal Candida isolates and their correlation with the presence of vulvovaginal candidiasis.

Materials and Methods

In total, 119 Candida albicans isolates from vaginal candidiasis were enrolled in the study. Egg yolk agar, Tween 80 opacity medium, and blood agar plate assays were used for the determination of phospholipase, esterase, and hemolytic activities, respectively.

Results

Based on the findings, 110 (92.44%) isolates showed phospholipase activity, 93 (78.2%) isolates were esterase producers, and 90 (75.6%) species had hemolytic activity.

Conclusion

This study showed that most of the tested isolates had different enzymatic patterns. Discrimination of variations in the production of these exoenzymes among different Candida isolates may depend on Candida spp. pathogenicity and could be responsible for the severity of symptoms among the patients.

Advancing biofilm management through nanoformulation strategies: a review of dosage forms and administration routes

Biofilms are complex microbial communities formed by the attachment of bacteria or fungi to surfaces encased in a self-produced polymeric matrix. These biofilms are highly resistant to conventional antimicrobial therapies. The resistance mechanisms exhibited by biofilms include low antibiotic absorption, sluggish replication, adaptive stress response, and the formation of dormant-like phenotypes. The eradication of biofilms requires alternative strategies and approaches. Nanotechnological drug delivery systems allow excellent control over the drug chemistry, surface area, particle size, particle shape, and composition of nanostructures. Nanoformulations can enhance the efficacy of antimicrobial agents by improving their bioavailability, stability, and targeted delivery to the site of infection that helps biofilm eradication more effectively. In addition to nanoformulations, the route of administration and choice of dosage forms play a crucial role in treating biofilm infections. Systemic administration of antibiotics is effective in controlling systemic infection and sepsis associated with biofilms. Alternative routes of administration, such as inhalation, vaginal, ocular, or dermal, have been explored to target biofilm infections in specific organs. This review primarily examines the utilisation of nanoformulations in various administration routes for biofilm management. It also provides an overview of biofilms, current approaches, and the drawbacks associated with conventional methods.

Elimination of Human Papillomavirus and Cervical Pathological Microbiota with Photodynamic Therapy in Women from Mexico City with Cervical Intraepithelial Neoplasia I

Cervical carcinoma (CC) is the second cause of cancer death in Mexican women. It starts with premalignant lesions known as Intraepithelial Cervical Neoplasia (CIN) that can develop due to infection by Human Papillomavirus (HPV) and other microorganisms. Current CIN therapy involves invasive methods that affect cervix integrity and fertility; we propose the use of photodynamic therapy (PDT) as a strategy with few side effects. In this work, the effectiveness of PDT for CIN I, HPV and pathogenic vaginal microbiota elimination in 29 women of Mexico City with CIN I, CIN I + HPV and HPV diagnosis was determined. After 6 months of PDT application, HPV infection was eliminated in 100% of the patients (P < 0.01), CIN I + HPV in 64.3% (P < 0.01) and CIN I in 57.2% (P > 0.05). PDT also eliminated pathogenic microorganisms: Chlamydia trachomatis in 81% of the women (P < 0.001) and Candida albicans in 80% (P < 0.05), without affecting normal microbiota since Lactobacillus iners was eliminated only in 5.8% of patients and the opportunistic Gardnerella vaginalis in 20%. These results show that PDT was highly effective in eradicating HPV and pathogenic microorganisms, suggesting that PDT is a promising therapy for cervical infections.

Bacterial amylases enable glycogen degradation by the vaginal microbiome

The human vaginal microbiota is frequently dominated by lactobacilli and transition to a more diverse community of anaerobic microbes is associated with health risks. Glycogen released by lysed epithelial cells is believed to be an important nutrient source in the vagina. However, the mechanism by which vaginal bacteria metabolize glycogen is unclear, with evidence implicating both bacterial and human enzymes. Here we biochemically characterize six glycogen-degrading enzymes (GDEs), all of which are pullanases (PulA homologues), from vaginal bacteria that support the growth of amylase-deficient Lactobacillus crispatus on glycogen. We reveal variations in their pH tolerance, substrate preferences, breakdown products and susceptibility to inhibition. Analysis of vaginal microbiome datasets shows that these enzymes are expressed in all community state types. Finally, we confirm the presence and activity of bacterial and human GDEs in cervicovaginal fluid. This work establishes that bacterial GDEs can participate in the breakdown of glycogen, providing insight into metabolism that may shape the vaginal microbiota.

Beyond fluconazole: A review of vulvovaginal candidiasis diagnosis and treatment

ABSTRACT

Vaginitis symptoms are among the most common reasons for patients to seek acute gynecological care. NPs who care for women and other patients with vaginas need to be up-to-date on diagnosis and treatment of vulvovaginal candidiasis (VVC) and recurrent VVC (RVVC). Two new antifungal medications for VVC are available. This article reviews vaginal physiology and provides an overview of VVC and RVVC pathophysiology, diagnosis, and treatment options.

The Upper Reproductive System Microbiome: Evidence beyond the Uterus

The microbiome of the female upper reproductive system has garnered increasing recognition and has become an area of interest in the study of women's health. This intricate ecosystem encompasses a diverse consortium of microorganisms (i.e., microbiota) and their genomes (i.e., microbiome) residing in the female upper reproductive system, including the uterus, the fallopian tubes, and ovaries. In recent years, remarkable advancements have been witnessed in sequencing technologies and microbiome research, indicating the potential importance of the microbial composition within these anatomical sites and its impact in women's reproductive health and overall well-being. Understanding the composition, dynamics, and functions of the microbiome of the female upper reproductive system opens up exciting avenues for improving fertility, treating gynecological conditions, and advancing our comprehension of the intricate interplay between the microbiome and the female reproductive system. The aim of this study is to compile currently available information on the microbial composition of the female upper reproductive system in humans, with a focus beyond the uterus, which has received more attention in recent microbiome studies compared with the fallopian tubes and ovaries. In conclusion, this review underscores the potential role of this microbiome in women's physiology, both in health and disease.

Collagen-Based Ovule Therapy Reduces Inflammation and Improve Cervical Epithelialization in Patients with Fungal, Viral, and Bacterial Cervico-Vaginitis

Background and Objectives: Vulvovaginal infections pose significant health challenges for women, necessitating effective treatment approaches. This retrospective observational study aimed at investigating the efficacy of collagen-based vaginal ovules therapy, specifically Plurigin Ovules, in restoring cervical epithelialization and reducing inflammation in mycotic, viral, and bacterial cervico-vaginitis. Materials and Methods: A total of 398 women with cervico-vaginitis were included in the study, categorized into three groups: bacterial cervico-vaginitis (Group A), viral cervico-vaginitis (Group B), and fungal cervico-vaginitis (Group C). Participants received vaginal therapy with Plurigin Ovules for three months. Vaginal health parameters were assessed at baseline (T0) and after six months (T1) using various diagnostic tests and analyzed with appropriate statistical tests. Results: Significant improvement in cervico-vaginitis was observed in all three groups. At T1, 87.7% patients of Group A, 66.7% of Group B, and 71.5% of Group C achieved infection resolution (all p < 0.05). Positive colposcopy results decreased across all groups (p < 0.001). Positive vaginal swabs and altered vaginal pH decreased in group A and C (p < 0.001). Positive HPV tests decreased in Group B (p < 0.001). Positive Pap tests and clinical examinations decreased significantly across all groups (p < 0.001). The odds ratios were calculated to reveal the significant associations between these diagnostic outcomes. The therapy was well-tolerated, and no major adverse events were reported. Conclusion: Plurigin Ovules exhibited promising therapeutic outcomes in the three cervico-vaginitis conditions studied. Bacterial cervico-vaginitis showed the most significant improvement, followed by fungal and viral cervico-vaginitis. These findings emphasize the potential of Plurigin Ovules as an effective therapeutic option for cervico-vaginal inflammation and infection, highlighting its role in promoting re-epithelialization and reducing inflammatory processes in the cervix and vagina.

Biofilm Formation and Aspartyl Proteinase Activity and Their Association with Azole Resistance Among Candida albicans Causing Vulvovaginal Candidiasis, Egypt

Background

Candida albicans (C. albicans) is a major cause of vulvovaginal candidiasis (VVC), a condition that is commonly treated with azole agents. Biofilm formation and aspartyl proteinase production are important virulence factors that could be linked to azole resistance in C. albicans impeding therapy.

Aim

To find out the association of both factors with azole resistance among C. albicans isolated from VVC cases in Egyptian nonpregnant women of childbearing age.

Patients and Methods

In a cross-sectional study, C. albicans was isolated from nonpregnant females diagnosed clinically as having VVC during a 1-year study period. Susceptibility to azole agents was tested using the disc diffusion method. Biofilm formation and aspartyl proteinase production were assessed phenotypically. Additionally, two biofilm-related genes (ALS1 and HWP1) and three proteinase genes (SAP2, SAP4, and SAP6) were screened for using polymerase chain reaction (PCR).

Results

Among 204 C. albicans isolates, azole resistance ratios were as follows: voriconazole (30.4%), itraconazole (17.6%), fluconazole (11.3%) and econazole (6.4%). Biofilm-producing capacity was detected in 63.2% of isolates, and 63.2% were proteinase producers. The frequencies of ALS1 and HWP1 were 69.6% and 74.5%, respectively, while SAP2, SAP4, and SAP6 were 69.2%, 88.7%, and 64.7%, respectively. Biofilm formation was significantly associated with azole resistance (P < 0.001 for each tested azole agent) as was proteinase production (P < 0.001 for fluconazole, voriconazole, and econazole resistance and P = 0.047 for itraconazole).

Conclusion

Among nonpregnant Egyptian women of childbearing age, azole resistance in C. albicans causing VVC is significantly associated with biofilm formation and proteinase production. The development of new therapeutic agents that can target these factors is warranted.

Performance and Safety of a New Medical Device (Polybactum) for Reducing the Recurrence Rate of Bacterial Vaginosis: Protocol for a Multicenter, Open-Label, Noncontrolled International Clinical Trial (POLARIS Study)

BACKGROUND

The medical literature has reported that recurrent bacterial vaginosis (RBV) has a relapse rate of 35% within 3 months and 60% within 12 months after antibiotic administration. Products that are able to provide a barrier effect against the biofilm produced by Gardnerella vaginalis could play a role in improving the results of bacterial vaginosis (BV) treatment.

OBJECTIVE

This study aims to assess the performance and safety of a medical device (Polybactum) containing polycarbophil, lauryl glucoside, and glycerides (PLGG) for reducing the rate of recurrence of BV.

METHODS

The study includes women who are aged above 18 years, are willing to provide signed informed consent, have a diagnosis of BV according to the Amsel criteria, and have been affected by at least 2 episodes of RBV in the last 12 months. The trial includes 2 phases. In the first phase (according to an open-label noncontrolled design), the treatment involving PLGG is administered for 3 cycles and is followed by a 1-month period of follow-up without treatment. In the second phase, a 9-month follow-up period is envisaged. Thus, for each patient, a 10-month follow-up period without treatment is planned. The study involves 5 centers (2 in Italy and 3 in Romania). We calculated a sample size of 44 pairs to achieve a power of 80% and a 1-sided significance of 5% for detecting a difference of 0.25 between marginal proportions, in comparison with the mean recurrence rate of BV reported in the medical literature. We estimated a potential dropout rate of 20%, and thus, we decided to enroll 55 patients (1-group chi-square test).

RESULTS

The study received ethics approval in 2016 in Romania and 1 year later in Italy. Recruitment started in September 2016. An interim analysis was performed in 2019, and full study analysis results are expected in July 2023.

CONCLUSIONS

The tested medical device involving PLGG could modify the mechanisms involved in the pathogenesis of BV and could improve microbiological parameters owing to the acidifying effect on vaginal pH. We believe that the findings of our study could be useful for other investigators who want to test different products against RBV using a standardized protocol and standardized procedures.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02863536; https://clinicaltrials.gov/ct2/show/NCT02863536.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/42787.

Neovaginoplasty With Nile Tilapia Skin: Cytological and Microbiota Evaluation

OBJECTIVES

To study the clinical, cytological, and vaginal microbiota findings in patients with Mayer-Rokitansky-Küster-Hauser syndrome who underwent neovaginoplasty using Nile tilapia fish skin.

METHODS

This is a cross-sectional study with 7 cisgender women with Mayer-Rokitansky-Küster-Hauser syndrome who had previously undergone neovagina reconstruction using Nile tilapia fish skin at a university hospital. Local institutional review board approval and written permission from the patient were obtained. Between August 2019 and November 2021, within 12 to 24 months after surgery, vaginal specimens were obtained for conventional oncotic and hormonal cytology, and for Gram staining. The Nugent scores were calculated. Colposcopy was also performed.

RESULTS

Squamous cells without atypia were found in all patients. Five patients had intermediate vaginal microbiota (Nugent score of 4), which was determined by the presence of few lactobacilli on Gram staining. In hormonal cytology, 4 patients presented with findings compatible with menacme. No colposcopic change was observed. When postsurgical dilation was performed correctly, a mean vaginal length of 8.3 cm was maintained after 1 year of follow-up.

CONCLUSIONS

Squamous cells without atypia were present in neovaginas with Nile tilapia fish skin. Most vaginal contents revealed intermediate microbiota and hormonal results compatible with menacme. Studies with a greater number of patients are necessary for a more comprehensive understanding of the microbiome in neovaginas with this new technique, thereby providing support for the treatment and prevention of associated pathologies.

Structural analysis of the Candida albicans mitochondrial DNA maintenance factor Gcf1p reveals a dynamic DNA-bridging mechanism

The compaction of mitochondrial DNA (mtDNA) is regulated by architectural HMG-box proteins whose limited cross-species similarity suggests diverse underlying mechanisms. Viability of Candida albicans, a human antibiotic-resistant mucosal pathogen, is compromised by altering mtDNA regulators. Among them, there is the mtDNA maintenance factor Gcf1p, which differs in sequence and structure from its human and Saccharomyces cerevisiae counterparts, TFAM and Abf2p. Our crystallographic, biophysical, biochemical and computational analysis showed that Gcf1p forms dynamic protein/DNA multimers by a combined action of an N-terminal unstructured tail and a long helix. Furthermore, an HMG-box domain canonically binds the minor groove and dramatically bends the DNA while, unprecedentedly, a second HMG-box binds the major groove without imposing distortions. This architectural protein thus uses its multiple domains to bridge co-aligned DNA segments without altering the DNA topology, revealing a new mechanism of mtDNA condensation.

Mycobiome Study Reveals Different Pathogens of Vulvovaginal Candidiasis Shape Characteristic Vaginal Bacteriome

Vulvovaginal candidiasis (VVC) can alter the vaginal microbiome composition and structure, and this may be correlated with its variable treatment efficacy. Integrated analysis of the mycobiome and bacteriome in VVC could facilitate accurate diagnosis of infected patients and further decipher the characterized bacteriome in different types of VVC. Our mycobiome analysis determined two common types of VVC, which were clustered into two community state types (CSTs) featured by Candida glabrata (CST I) and Candida albicans (CST II). Subsequently, we compared the vaginal bacteriome in two CSTs of VVC and two other types of reproductive tract infections (RTIs), bacterial vaginosis (BV) and Ureaplasma urealyticum (UU) infection. The vaginal bacteriome in VVC patients was between the healthy and other RTIs (BV and UU) status, it bore the greatest resemblance to that of healthy subjects. While BV and UU patients have the unique vaginal microbiota community structure, which very different with healthy women. Compared with CST II, the vaginal bacteriome of CST I VVC was characterized by Prevotella, a key signature in BV. In comparison, CST II was featured by Ureaplasma, the pathogen of UU. The findings of our study highlight the need for co-analysis and simultaneous consideration of vaginal mycobiome and bacteriome in the diagnosis and treatment of VVC to solve common clinical problems, such as unsatisfactory cure rates and recurrent symptoms. IMPORTANCE Fungi headed by C. albicans play a critical role in VVC but are not sufficient for its occurrence, indicating the involvement of other factors, such as the vaginal bacteriome. We found that different CST correspond to different bacterial composition in patients with VVC, and this could underlie the alteration of vaginal microorganism environment in VVC patients. We believe that this correlation should not be ignored, and it may be related to the unsatisfactory treatment outcomes and high recurrence rate of VVC. Here, we provided evidence for associations between vaginal bacteriome patterns and fungal infection. Screening specific biomarkers for three common RTIs paves a theoretical basis for further development of personalized precision treatment.

Learning the language of pathogens

Parasites can use extracellular vesicles and cellular projections called cytonemes to communicate with one another.

Production of IgY against iron permease Ftr1 from Candida albicans and evaluation of its antifungal activity using Galleria mellonella as a model of systemic infection

Candida albicans is one of the leading pathological agents of mucosal and deep tissue infections. Considering that the variety of antifungals is restricted and that toxicity limits their use, immunotherapies against pathogenic fungi have been viewed as alternatives with reduced adverse effects. In this context, C. albicans has a protein used to capture iron from the environment and the host, known as the high-affinity iron permease Ftr1. This protein may be a new target of action for novel antifungal therapies, as it influences the virulence of this yeast. Thus, the aim of the present study was to produce and conduct the biological characterization of IgY antibodies against C. albicans Ftr1. Immunization of laying hens with an Ftr1-derived peptide resulted in IgY antibodies extracted from egg yolks capable of binding to the antigen with high affinity (avidity index = 66.6 ± 0.3%). These antibodies reduced the growth and even eliminated C. albicans under iron restriction, a favorable condition for the expression of Ftr1. This also occurred with a mutant strain that does not produce Ftr1 in the presence of iron, a circumstance in which the protein analog of iron permease, Ftr2, is expressed. Furthermore, the survival of G. mellonella larvae infected with C. albicans and treated with the antibodies was 90% higher than the control group, which did not receive treatment (p < 0.0001). Therefore, our data suggest that IgY antibodies against Ftr1 from C. albicans can inhibit yeast propagation by blocking iron uptake.

The Interplay between Candida albicans, Vaginal Mucosa, Host Immunity and Resident Microbiota in Health and Disease: An Overview and Future Perspectives

Vulvovaginal candidiasis (VVC), which is primarily caused by Candida albicans, is an infection that affects up to 75% of all reproductive-age women worldwide. Recurrent VVC (RVVC) is defined as >3 episodes per year and affects nearly 8% of women globally. At mucosal sites of the vagina, a delicate and complex balance exists between Candida spp., host immunity and local microbial communities. In fact, both immune response and microbiota composition play a central role in counteracting overgrowth of the fungus and maintaining homeostasis in the host. If this balance is perturbed, the conditions may favor C. albicans overgrowth and the yeast-to-hyphal transition, predisposing the host to VVC. To date, the factors that affect the equilibrium between Candida spp. and the host and drive the transition from C. albicans commensalism to pathogenicity are not yet fully understood. Understanding the host- and fungus-related factors that drive VVC pathogenesis is of paramount importance for the development of adequate therapeutic interventions to combat this common genital infection. This review focuses on the latest advances in the pathogenic mechanisms implicated in the onset of VVC and also discusses novel potential strategies, with a special focus on the use of probiotics and vaginal microbiota transplantation in the treatment and/or prevention of recurrent VVC.

Fungi and cancer

The microbiome may impact cancer development, progression and treatment responsiveness, but its fungal components remain insufficiently studied in this context. In this review, we highlight accumulating evidence suggesting a possible involvement of commensal and pathogenic fungi in modulation of cancer-related processes. We discuss the mechanisms by which fungi can influence tumour biology, locally by activity exerted within the tumour microenvironment, or remotely through secretion of bioactive metabolites, modulation of host immunity and communications with neighbouring bacterial commensals. We examine prospects of utilising fungi-related molecular signatures in cancer diagnosis, patient stratification and assessment of treatment responsiveness, while highlighting challenges and limitations faced in performing such research. In all, we demonstrate that fungi likely constitute important members of mucosal and tumour-residing microbiomes. Exploration of fungal inter-kingdom interactions with the bacterial microbiome and the host and decoding of their causal impacts on tumour biology may enable their harnessing into cancer diagnosis and treatment.

Interplay of the microbiome and antifungal therapy in recurrent vulvovaginal candidiasis (RVVC): A narrative review

Recurrent vulvovaginal candidiasis (RVVC) is a microbial, immune and sexual health disorder impacting up to 10 % of the adult female population. Fluconazole is a well-established antifungal drug commonly utilized for acute and long-term RVVC treatment. This insight review provides an overview of known vaginal and gastrointestinal microbiota characteristics in RVVC, presents the potential impacts of fluconazole therapy on multi-microbiome relationships and discusses implications for future research and clinical practice. Next-generation sequencing (NGS) and molecular methods to accurately define vaginal microbiota trends in RVVC are not comprehensively available, limiting understanding of microbiota roles in RVVC. Inconsistencies and variances in Lactobacillus profiles in RVVC women suggest poorly understood disease implications on the bacterial and fungal microbiomes. Investigations of environmental conditions like vaginal pH, drug therapy's impact, especially fluconazole maintenance therapy, and the elucidation of multi-microbiome relationships in RVVC are required to further investigate disease pathogenesis and responsible antimicrobial prescribing.

Bacterial-fungal interactions and their impact on microbial pathogenesis

Microbial communities of the human microbiota exhibit diverse effects on human health and disease. Microbial homeostasis is important for normal physiological functions and changes to the microbiota are associated with many human diseases including diabetes, cancer, and colitis. In addition, there are many microorganisms that are either commensal or acquired from environmental reservoirs that can cause diverse pathologies. Importantly, the balance between health and disease is intricately connected to how members of the microbiota interact and affect one another's growth and pathogenicity. However, the mechanisms that govern these interactions are only beginning to be understood. In this review, we outline bacterial-fungal interactions in the human body, including examining the mechanisms by which bacteria govern fungal growth and virulence, as well as how fungi regulate bacterial pathogenesis. We summarize advances in the understanding of chemical, physical, and protein-based interactions, and their role in exacerbating or impeding human disease. We focus on the three fungal species responsible for the majority of systemic fungal infections in humans: Candida albicans, Cryptococcus neoformans, and Aspergillus fumigatus. We conclude by summarizing recent studies that have mined microbes for novel antimicrobials and antivirulence factors, highlighting the potential of the human microbiota as a rich resource for small molecule discovery.